{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T17:39:17Z","timestamp":1787161157646,"version":"build-2736575974"},"reference-count":74,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2021,3,17]],"date-time":"2021-03-17T00:00:00Z","timestamp":1615939200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Schwartz Foundation","award":["Grant number not applicable"],"award-info":[{"award-number":["Grant number not applicable"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["TropicalMed"],"abstract":"<jats:p>Human polymicrobial infections in tick-borne disease (TBD) patients is an emerging public health theme. However, the requirement for holistic TBD tests in routine clinical laboratories is ambiguous. TICKPLEX\u00ae PLUS is a holistic TBD test utilized herein to assess the need for multiplex and multifunctional diagnostic tools in a routine clinical laboratory. The study involved 150 specimens categorized into Lyme disease (LD)-positive (n = 48), LD-negative (n = 30), and febrile patients from whom borrelia serology was requested (n = 72, later \u201cfebrile patients\u201d) based on reference test results from United Medix, Finland. Reference tests from DiaSorin, Immunetics, and Mikrogen Diagnostik followed the two-tier LD testing system. A comparison between the reference tests and TICKPLEX\u00ae PLUS produced 86%, 88%, and 87% positive, negative, and overall agreement, respectively. Additionally, up to 15% of LD and 11% of febrile patients responded to TBD related coinfections and opportunistic microbes. The results demonstrated that one (TICKPLEX\u00ae PLUS) test can aid in a LD diagnosis instead of four tests. Moreover, TBD is not limited to just LD, as the specimens produced immune responses to several TBD microbes. Lastly, the study indicated that the screening of febrile patients for TBDs could be a missed opportunity at reducing unreported patient cases.<\/jats:p>","DOI":"10.3390\/tropicalmed6010038","type":"journal-article","created":{"date-parts":[[2021,3,17]],"date-time":"2021-03-17T21:43:31Z","timestamp":1616017411000},"page":"38","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Assessing the Need for Multiplex and Multifunctional Tick-Borne Disease Test in Routine Clinical Laboratory Samples from Lyme Disease and Febrile Patients with a History of a Tick Bite"],"prefix":"10.3390","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4346-027X","authenticated-orcid":false,"given":"Kunal","family":"Garg","sequence":"first","affiliation":[{"name":"Tezted Ltd., Mattilaniemi 6-8, 40100 Jyv\u00e4skyl\u00e4, Finland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"T. Sakari","family":"Jokiranta","sequence":"additional","affiliation":[{"name":"United Medix Laboratories, Kivihaantie 7, 00310 Helsinki, Finland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sanna","family":"Fil\u00e9n","sequence":"additional","affiliation":[{"name":"United Medix Laboratories, Kivihaantie 7, 00310 Helsinki, Finland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7470-5770","authenticated-orcid":false,"given":"Leona","family":"Gilbert","sequence":"additional","affiliation":[{"name":"Tezted Ltd., Mattilaniemi 6-8, 40100 Jyv\u00e4skyl\u00e4, Finland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,3,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1128\/CMR.18.3.484-509.2005","article-title":"Diagnosis of lyme borreliosis","volume":"18","author":"Wang","year":"2005","journal-title":"Clin. Microbiol Rev."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"568","DOI":"10.1080\/07853890500431934","article-title":"Epidemiology and diagnosis of Lyme borreliosis","volume":"37","author":"Wilske","year":"2005","journal-title":"Ann. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"571","DOI":"10.1097\/00000372-199612000-00004","article-title":"Heterogeneity of Borrelia burgdorferi in the skin","volume":"18","author":"Aberer","year":"1996","journal-title":"Am. J. Dermatopathol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1267","DOI":"10.1093\/cid\/ciu106","article-title":"Lyme Disease: Neurology, Neurobiology, and Behavior","volume":"58","author":"Halperin","year":"2014","journal-title":"Clin. Infect. Dis."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"96.e1","DOI":"10.1016\/j.cmi.2014.07.004","article-title":"A retrospective serological survey on human babesiosis in Belgium","volume":"21","author":"Lempereur","year":"2015","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1420","DOI":"10.1128\/CVI.00308-07","article-title":"Anaplasma phagocytophilum-Borrelia burgdorferi Coinfection Enhances Chemokine, Cytokine, and Matrix Metalloprotease Expression by Human Brain Microvascular Endothelial Cells","volume":"14","author":"Grab","year":"2007","journal-title":"Clin. Vaccine Immunol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1016\/j.cll.2009.10.004","article-title":"Human Ehrlichiosis and Anaplasmosis","volume":"30","author":"Ismail","year":"2010","journal-title":"Clin. Lab. Med."},{"key":"ref_8","unstructured":"Steffen, R. (2016). Epidemiology of tick-borne encephalitis (TBE) in international travellers to Western\/Central Europe and conclusions on vaccination recommendations. J. Travel Med., 23."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Davidsson, M. (2018). The Financial Implications of a Well-Hidden and Ignored Chronic Lyme Disease Pandemic. Healthcare, 6.","DOI":"10.3390\/healthcare6010016"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Karim, S., Budachetri, K., Mukherjee, N., Williams, J., Kausar, A., Hassan, M., Adamson, S., Dowd, S.E., Apanskevich, D., and Arijo, A. (2017). A study of ticks and tick-borne livestock pathogens in Pakistan. PLoS Neglect. Trop. D, 11.","DOI":"10.1371\/journal.pntd.0005681"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"556","DOI":"10.1186\/s13071-018-3131-y","article-title":"Tick-borne pathogens in Finland: Comparison of Ixodes ricinus and I. persulcatus in sympatric and parapatric areas","volume":"11","author":"Laaksonen","year":"2018","journal-title":"Parasite Vector"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"168","DOI":"10.1186\/s13071-016-1449-x","article-title":"Tick-borne bacterial pathogens in southwestern Finland","volume":"9","author":"Sormunen","year":"2016","journal-title":"Parasite Vector"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"101449","DOI":"10.1016\/j.ttbdis.2020.101449","article-title":"Monitoring of ticks and tick-borne pathogens through a nationwide research station network in Finland","volume":"11","author":"Sormunen","year":"2020","journal-title":"Ticks Tick Borne Dis."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"DeLong, A., Hsu, M., and Kotsoris, H. (2019). Estimation of cumulative number of post-treatment Lyme disease cases in the US, 2016 and 2020. BMC Public Health, 19.","DOI":"10.1186\/s12889-019-6681-9"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e200328","DOI":"10.1001\/jamanetworkopen.2020.0328","article-title":"Challenges in Predicting Lyme Disease Risk","volume":"3","author":"Kugeler","year":"2020","journal-title":"JAMA Netw. Open"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1089\/vbz.2017.2127","article-title":"Brave New Worlds: The Expanding Universe of Lyme Disease","volume":"17","author":"Stone","year":"2017","journal-title":"Vector-Borne Zoonot"},{"key":"ref_17","unstructured":"Centers for Disease Control and Prevention (CDC) (2019, February 16). How Many People Get Lyme Disease?, Available online: https:\/\/www.cdc.gov\/lyme\/stats\/humancases.html."},{"key":"ref_18","unstructured":"European Centre for Disease Prevention and Control (2019, May 28). ECDC Comment: European Commission Updates Communicable Disease Surveillance List\u2014Lyme Neuroborreliosis Now under EU\/EEA Surveillance. Available online: https:\/\/www.ecdc.europa.eu\/en\/news-events\/ecdc-comment-european-commission-updates-communicable-disease-surveillance-list-lyme."},{"key":"ref_19","unstructured":"Parliament, E. (2019, May 28). European Parliament Resolution of 15 November 2018 on Borrelia Infection. Strasbourg 2018. Available online: https:\/\/www.europarl.europa.eu\/doceo\/document\/TA-8-2018-0465_SV.html?redirect."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1016\/j.medmal.2018.11.011","article-title":"Review of European and American guidelines for the diagnosis of Lyme borreliosis","volume":"49","author":"Eldin","year":"2019","journal-title":"M\u00e9decine Mal. Infect"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Waddell, L.A., Greig, J., Mascarenhas, M., Harding, S., Lindsay, R., and Ogden, N. (2016). The Accuracy of Diagnostic Tests for Lyme Disease in Humans, A Systematic Review and Meta-Analysis of North American Research. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0168613"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Leeflang, M.M., Ang, C.W., Berkhout, J., Bijlmer, H.A., Bortel, W.V., Brandenburg, A.H., Burgel, N.D.V., Dam, A.P.V., Dessau, R.B., and Fingerle, V. (2016). The diagnostic accuracy of serological tests for Lyme borreliosis in Europe: A systematic review and meta-analysis. BMC Infect Dis., 16.","DOI":"10.1186\/s12879-016-1468-4"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1074","DOI":"10.1093\/cid\/cix043","article-title":"Evaluation of Modified 2-Tiered Serodiagnostic Testing Algorithms for Early Lyme Disease","volume":"64","author":"Branda","year":"2017","journal-title":"Clin. Infect. Dis."},{"key":"ref_24","unstructured":"Centers for Disease Control and Prevention (CDC) (1995). Recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease. MMWR. Morb. Mortal. Wkly. Rep., 44, 590\u2013591."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"15932","DOI":"10.1038\/s41598-018-34393-9","article-title":"Evaluating polymicrobial immune responses in patients suffering from tick-borne diseases","volume":"8","author":"Garg","year":"2018","journal-title":"Sci. Rep."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1016\/j.ttbdis.2015.10.005","article-title":"Testing practices and volume of non-Lyme tickborne diseases in the United States","volume":"7","author":"Connally","year":"2016","journal-title":"Ticks Tick-Borne Dis."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"427","DOI":"10.2147\/IJGM.S122313","article-title":"Commercial test kits for detection of Lyme borreliosis: A meta-analysis of test accuracy","volume":"9","author":"Cook","year":"2016","journal-title":"Int. J. Gen. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1111\/j.1574-695X.1994.tb00437.x","article-title":"Antigens of Lyme disease of spirochaete Borrelia burgdorferi inhibits antigen or mitogen-induced lymphocyte proliferation","volume":"8","author":"Chiao","year":"1994","journal-title":"FEMS Immunol. Med. Mic."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"S64","DOI":"10.1086\/516163","article-title":"Why is chronic Lyme borreliosis chronic?","volume":"25","author":"Aberer","year":"1997","journal-title":"Clin. Infect. Dis."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Chung, Y., Zhang, N., and Wooten, R.M. (2013). Borrelia burgdorferi elicited-IL-10 suppresses the production of inflammatory mediators, phagocytosis, and expression of co-stimulatory receptors by murine macrophages and\/or dendritic cells. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0084980"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1111\/j.1365-2249.2006.03245.x","article-title":"Decreased up-regulation of the interleukin-12Rbeta2-chain and interferon-gamma secretion and increased number of forkhead box P3-expressing cells in patients with a history of chronic Lyme borreliosis compared with asymptomatic Borrelia-exposed individuals","volume":"147","author":"Jarefors","year":"2007","journal-title":"Clin. Exp. Immunol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1128\/IAI.02471-14","article-title":"CD4+ T cells promote antibody production but not sustained affinity maturation during Borrelia burgdorferi infection","volume":"83","author":"Elsner","year":"2015","journal-title":"Infect Immun."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Elsner, R.A., Hastey, C.J., Olsen, K.J., and Baumgarth, N. (2015). Suppression of Long-Lived Humoral Immunity Following Borrelia burgdorferi Infection. PLoS Pathog., 11.","DOI":"10.1371\/journal.ppat.1004976"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Tunev, S.S., Hastey, C.J., Hodzic, E., Feng, S., Barthold, S.W., and Baumgarth, N. (2011). Lymphoadenopathy during lyme borreliosis is caused by spirochete migration-induced specific B cell activation. PLoS Pathog., 7.","DOI":"10.1371\/journal.ppat.1002066"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"5612","DOI":"10.4049\/jimmunol.1103735","article-title":"Delays and diversions mark the development of B cell responses to Borrelia burgdorferi infection","volume":"188","author":"Hastey","year":"2012","journal-title":"J. Immunol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Aberer, E., and Schwantzer, G. (2012). Course of Antibody Response in Lyme Borreliosis Patients before and after Therapy. ISRN Immunol, 1\u20134.","DOI":"10.5402\/2012\/719821"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1080\/000155500459312","article-title":"Long-term serological follow-up of patients treated for chronic cutaneous borreliosis or culture-positive erythema migrans","volume":"80","author":"Lomholt","year":"2000","journal-title":"Acta Derm. Venereol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"116","DOI":"10.3389\/fimmu.2017.00116","article-title":"Borrelia burgdorferi Manipulates Innate and Adaptive Immunity to Establish Persistence in Rodent Reservoir Hosts","volume":"8","author":"Tracy","year":"2017","journal-title":"Front Immunol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"2033","DOI":"10.2217\/fmb.15.114","article-title":"Emerging horizons for tick-borne pathogens: From the \u201cone pathogen-one disease\u201d vision to the pathobiome paradigm","volume":"10","author":"Kazimirova","year":"2015","journal-title":"Future Microbiol."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Aucott, J., Morrison, C., Munoz, B., Rowe, P.C., Schwarzwalder, A., and West, S.K. (2009). Diagnostic challenges of early Lyme disease: Lessons from a community case series. BMC Infect Dis., 9.","DOI":"10.1186\/1471-2334-9-79"},{"key":"ref_41","first-page":"e14","article-title":"Misdiagnosis of early Lyme disease as the summer flu","volume":"3","author":"Aucott","year":"2011","journal-title":"Orthop. Rev."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"e322","DOI":"10.7717\/peerj.322","article-title":"Severity of chronic Lyme disease compared to other chronic conditions: A quality of life survey","volume":"2","author":"Johnson","year":"2014","journal-title":"PeerJ"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"158","DOI":"10.2174\/1874205X01206010158","article-title":"Chronic Lyme Disease and Co-infections: Differential Diagnosis","volume":"6","author":"Berghoff","year":"2012","journal-title":"Open Neurol. J."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"783","DOI":"10.3201\/eid1805.111366","article-title":"Bartonella spp. bacteremia and rheumatic symptoms in patients from Lyme disease-endemic region","volume":"18","author":"Maggi","year":"2012","journal-title":"Emerg. Infect Dis."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"859","DOI":"10.1007\/s100960050420","article-title":"Multiple Mycoplasmal Infections Detected in Blood of Patients with Chronic Fatigue Syndrome and\/or Fibromyalgia Syndrome","volume":"18","author":"Nasralla","year":"1999","journal-title":"Eur. J. Clin. Microbiol. Infect Dis."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1034\/j.1600-0463.2003.1110504.x","article-title":"Multiple co-infections (Mycoplasma, Chlamydia, human herpes virus-6) in blood of chronic fatigue syndrome patients: Association with signs and symptoms","volume":"111","author":"Nicolson","year":"2003","journal-title":"Apmis"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1159","DOI":"10.1038\/s41431-019-0386-5","article-title":"The GDPR and the research exemption: Considerations on the necessary safeguards for research biobanks","volume":"27","author":"Staunton","year":"2019","journal-title":"Eur. J. Hum. Genet."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1675","DOI":"10.1373\/clinchem.2010.150672","article-title":"Human Tissue Ownership and Use in Research: What Laboratorians and Researchers Should Know","volume":"56","author":"Allen","year":"2010","journal-title":"Clin. Chem."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"648","DOI":"10.1136\/bmj.325.7365.648","article-title":"For and against: No consent should be needed for using leftover body material for scientific purposes For Against","volume":"325","author":"Savulescu","year":"2002","journal-title":"BMJ"},{"key":"ref_50","unstructured":"(2019, February 20). Health, M. of S.A. and Act on the Medical Use of Human Organs, Tissues and Cells. Available online: https:\/\/www.finlex.fi\/fi\/laki\/ajantasa\/2001\/20010101."},{"key":"ref_51","unstructured":"(2019, February 20). Health, M. of S.A. and Medical Research Act. Available online: https:\/\/www.finlex.fi\/en\/laki\/kaannokset\/1999\/en19990488."},{"key":"ref_52","unstructured":"(2019, February 20). Standardization, I.O. for ISO 15189:2012 Medical Laboratories\u2014Requirements for Quality and Competence. Available online: https:\/\/www.iso.org\/standard\/56115.html."},{"key":"ref_53","first-page":"1235","article-title":"Use of coefficient of variation in assessing variability of quantitative assays","volume":"9","author":"Reed","year":"2002","journal-title":"Clin. Diagn. Lab. Immunol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"1167","DOI":"10.1016\/j.theriogenology.2010.01.003","article-title":"Method agreement analysis: A review of correct methodology","volume":"73","author":"Watson","year":"2010","journal-title":"Theriogenology"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"276","DOI":"10.11613\/BM.2012.031","article-title":"Interrater reliability: The kappa statistic","volume":"22","author":"McHugh","year":"2012","journal-title":"Biochem. Med."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"152","DOI":"10.5395\/rde.2017.42.2.152","article-title":"Statistical notes for clinical researchers: Chi-squared test and Fisher\u2019s exact test","volume":"42","author":"Kim","year":"2017","journal-title":"Restor Dent. Endod."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"e00601","DOI":"10.1128\/JCM.00601-18","article-title":"Serological Diagnostics of Lyme Borreliosis: Comparison of Universal and Borrelia Species-Specific Tests Based on Whole-Cell and Recombinant Antigens","volume":"56","author":"Kodym","year":"2018","journal-title":"J. Clin. Microbiol."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"1657","DOI":"10.1001\/jama.1996.03530450047031","article-title":"Concurrent Lyme disease and babesiosis. Evidence for increased severity and duration of illness","volume":"275","author":"Krause","year":"1996","journal-title":"JAMA"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"353","DOI":"10.3201\/eid1202.050765","article-title":"Borrelia burgdorferi and Anaplasma phagocytophilum Coinfection","volume":"12","author":"Loebermann","year":"2006","journal-title":"Emerg. Infect Dis."},{"key":"ref_60","first-page":"187","article-title":"Human Granulocytic Ehrlichiosis as a Common Cause of Tick-associated Fever in Southeast Sweden: Report from a Prospective Clinical Study","volume":"34","author":"Berglund","year":"2009","journal-title":"Scand. J. Infect Dis."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1016\/j.ttbdis.2015.12.010","article-title":"Serological and molecular evidence for spotted fever group Rickettsia and Borrelia burgdorferi sensu lato co-infections in The Netherlands","volume":"7","author":"Koetsveld","year":"2016","journal-title":"Ticks Tick-Borne Dis."},{"key":"ref_62","doi-asserted-by":"crossref","unstructured":"Qiu, Y., Nakao, R., Ohnuma, A., Kawamori, F., and Sugimoto, C. (2014). Microbial Population Analysis of the Salivary Glands of Ticks; A Possible Strategy for the Surveillance of Bacterial Pathogens. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0103961"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"817","DOI":"10.1007\/s11252-019-00854-w","article-title":"High tick abundance and diversity of tick-borne pathogens in a Finnish city","volume":"22","author":"Klemola","year":"2019","journal-title":"Urban Ecosyst."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"349","DOI":"10.3109\/00365549409011805","article-title":"Prevalence of Borrelia burgdorferi in selected tick populations in Finland","volume":"26","author":"Junttila","year":"1994","journal-title":"Scand J. Infect Dis"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"1116","DOI":"10.3201\/eid1607.091905","article-title":"Fatal babesiosis in man, Finland, 2004","volume":"16","author":"Haapasalo","year":"2010","journal-title":"Emerg. Infect Dis."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1016\/S0002-9343(02)01440-7","article-title":"Systemic symptoms without erythema migrans as the presenting picture of early Lyme disease","volume":"114","author":"Steere","year":"2003","journal-title":"Am. J. Med."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"2023","DOI":"10.1086\/324490","article-title":"Laboratory diagnostic techniques for patients with early Lyme disease associated with erythema migrans: A comparison of different techniques","volume":"33","author":"Nowakowski","year":"2001","journal-title":"Clin. Infect. Dis."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"1434","DOI":"10.1086\/320160","article-title":"Tickborne Infections as a Cause of Nonspecific Febrile Illness in Wisconsin","volume":"32","author":"Belongia","year":"2001","journal-title":"Clin. Infect. Dis."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"179","DOI":"10.3389\/fneur.2015.00179","article-title":"A Practical Guide to Immunoassay Method Validation","volume":"6","author":"Andreasson","year":"2015","journal-title":"Front. Neurol."},{"key":"ref_70","doi-asserted-by":"crossref","unstructured":"Crowther, J.R. (2001). The ELISA Guidebook, Humana Press Inc.","DOI":"10.1385\/1592590497"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1099\/mic.0.000027","article-title":"Morphological and biochemical features of Borrelia burgdorferi pleomorphic forms","volume":"161","author":"Herranen","year":"2015","journal-title":"Microbiology"},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1016\/j.micinf.2016.04.002","article-title":"Pleomorphic forms of Borrelia burgdorferi induce distinct immune responses","volume":"18","author":"Brander","year":"2016","journal-title":"Microb Infect"},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"3979","DOI":"10.1128\/IAI.71.7.3979-3987.2003","article-title":"Borrelia burgdorferi-induced tolerance as a model of persistence via immunosuppression","volume":"71","author":"Diterich","year":"2003","journal-title":"Infect Immun."},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1128\/CVI.00367-10","article-title":"Acute Parvovirus B19 Infection Causes Nonspecificity Frequently in Borrelia and Less Often in Salmonella and Campylobacter Serology, Posing a Problem in Diagnosis of Infectious Arthropathy","volume":"18","author":"Tuuminen","year":"2011","journal-title":"Clin. Vaccine Immunol."}],"container-title":["Tropical Medicine and Infectious Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2414-6366\/6\/1\/38\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T05:37:21Z","timestamp":1760161041000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2414-6366\/6\/1\/38"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,3,17]]},"references-count":74,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2021,3]]}},"alternative-id":["tropicalmed6010038"],"URL":"https:\/\/doi.org\/10.3390\/tropicalmed6010038","relation":{},"ISSN":["2414-6366"],"issn-type":[{"value":"2414-6366","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,3,17]]}}}